Neil Fleshner is a professor of surgery and Martin Barkin chair of urology, University of Toronto. He is also the Love Chair in Prostate Cancer Prevention, at the Princess Margaret Cancer Centre
The Ontario Health Technology Advisory Committee has decided that the benefits of robotic prostate-cancer surgery do not warrant public-purse funding in comparison with the standard open procedure in light of an extra $3,224 per case. As a surgeon who has performed almost 3,000 prostate-cancer surgeries, I'm deeply disappointed.
My melancholy about this decision stems from a variety of additional concerns: Yes, this means I cannot practice my art and science in a state-of-the-art setting. But even more so, as an educator, researcher and proud Canadian, this move evokes deep anxiety.
This decision severely curtails Ontario's ability to compete in the globally competitive market for medical talent and significantly handicaps our future surgeons' skill set.
Let me be more specific: Ontario and University of Toronto affiliated hospitals have historically been recognized as leaders in medical education and research. This has been particularly true in the field of prostate cancer, where many of the standards of practice throughout the globe have been established. Robotic prostate-cancer surgery is the gold-standard method throughout the European Union and the United States. Even the National Health Service in Britain – hardly a publicly funded system known for its ability to keep up with technological change – fund the robotic approach.
If we have no access to this technology, how can we ensure that the finest medical trainees, many whom come from all corners of the globe, choose Toronto as a destination to come train and help look after patients in Ontario? Without a robotic prostate program we would immediately lose our standing as a top-five centre for surgical prostate-cancer training in the world. Indeed,we would become a laughing stock among our global colleagues and peers.
Ontario citizens should also realize that this decision also influences their own access to better health outcomes. How so? Regardless of the debate in the context of prostate cancer, one thing that's certain is that robotic surgery is here to stay. We are still in the infancy in terms of robotic surgery. Newer and cheaper robots are around the corner and will not disappear from the surgical lexicon.
More and more procedures will be perfected. When that day comes and the robots are inexpensive and outcomes better – who will be trained to do these procedures? According to OHTAC – no one. The reason for this is that without a broad set of robotically trained surgical residents, an entire generation of surgeons will be trained without the skills required to perform the tasks. As a robotic surgeon myself (from time to time), I can say that skill acquisition is a steep learning curve and research suggests that hundreds of cases are required to perfect this technique.
Where does the solution lie to this conundrum? In my view, as a proud Canadian we must recognize that for our patients to have the best chance at long-term health outcomes, our young surgeons must be trained with the latest technology. Centres of excellence and teaching hospitals must have access to the operating rooms of the future. This cannot only be sustained by philanthropy, as it has to date in a handful of institutions throughout the province.
Health-care decision-makers must step up and make this a priority in order to allow us to maintain a global standing in research and academia and, more importantly, invest in the future health of our citizens.